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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION I - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br /> its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br /> within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br /> this form is completed and returned. <br /> FACILITY NAME: C�1 Q CKTO N <br /> FACILITY ADDRESS: j rl C �Q� <br /> TANK ID #39 - TANK SIZE: W,000 PREVIOUS TANK CONTENTS: <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: SEMCO <br /> Address: 1217 South 7th Street City: Modesto Zip: 95351 <br /> Phone#: ( 209 ) 524-9653 Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: SEMOD <br /> Address: 1217 South 7th Street City: Modesto zip: 95351 <br /> Phone #: ( 209 } 524--9653 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Title: Signature: Date <br /> SECTION 4- To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: <br /> Address: City: Zip: <br /> Phone#: { } <br /> Date Tanis Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 10/19198) Page 10 <br />